1710979695 NPI number — DR. ERIK L. RUSSELL M.D.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1710979695 NPI number — DR. ERIK L. RUSSELL M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
RUSSELL
Provider First Name:
ERIK
Provider Middle Name:
L.
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1710979695
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/18/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
281 MOIKE PL
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
KAHULUI
Provider Business Mailing Address State Name:
HI
Provider Business Mailing Address Postal Code:
96732-1106
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
808-793-8943
Provider Business Mailing Address Fax Number:
808-495-0159

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
281 MOIKE PL
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
KAHULUI
Provider Business Practice Location Address State Name:
HI
Provider Business Practice Location Address Postal Code:
96732-1106
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
808-793-8943
Provider Business Practice Location Address Fax Number:
808-495-0159
Provider Enumeration Date:
08/17/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X , with the licence number:  D0043623 , registered in the state of MD ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207R00000X , with the licence number: MD-17813 , registered in the state of HI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 110223993 . This is a "RR MEDICARE" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: 4492738 . This is a "AETNA FEE FOR SERVICE" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: P14805 . This is a "CAREFIRST MPOS" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: 1325758 . This is a "CIGNA PIN" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: 283838 . This is a "MAMSI SPECIALISTV" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: 025440 . This is a "JHHC PROVIDER NUMBER" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: 312871700 , issued by the state of ( MD ) . This identifiers is of the category "MEDICAID".
  • Identifier: 691700 . This is a "AETNA CAPITATED" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: 532650-04 . This is a "CAREFIRST MD RENDERING" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: 883838 . This is a "MAMSI PRIMARY CARE" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: 7605-0044 . This is a "CAREFIRST BLUECHOICE" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".




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